Medical Assistance Program

Application Process

1. Download Required Forms: Select and complete the appropriate assistance form:
- Medical Assistance Form
- Dental Assistance Form
- Other Assistance Form

2. Complete HIPAA Form: Download, fill out, and include HIPAA Form with submission

3. Gather Supporting Documentation:
- Financial documents establishing financial need
- Dental plan (if applicable)
- Medical provider statements or bills
- Proof of insurance coverage/denials
- Evidence of attempts to seek financial assistance from providers

4. Submit Application:
- Email completed application and all supporting documentation to: charity@vikingsofsolvang.org

5. Follow-up: Organization may contact applicant to request additional information

Required Information

• First Name, Last Name
• Email, Phone
• Full Address (Address Line 1, Address Line 2, City, State, Zip Code, Country)
• Years at current address
• Date of Birth
• Name of Parent/Guardian (if applicable)
• Description of medical condition/diagnosis and how organization can best serve
• Employer and Insurance information
• Doctor information
• Date of Last Visit
• How you heard about the program

Questions to Address

• Tell us about your medical condition and/or diagnosis and how we can best serve you.